Chiropractic & Osteopathy BioMed Central Research Open Access Neuro Emotional Technique for the treatment of trigger point sensitivity in chronic neck pain sufferers: A controlled clinical trial Peter Bablis1, Henry Pollard*1,2 and Rod Bonello1 Address: 1Macquarie Injury Management Group, Macquarie University, Sydney, Australia and 2Director of Research, ONE Research Foundation, Encinitas, California, USA Email: Peter Bablis - [email protected]; Henry Pollard* - [email protected]; Rod Bonello - [email protected] * Corresponding author Published: 21 May 2008 Received: 12 May 2007 Accepted: 21 May 2008 Chiropractic & Osteopathy 2008, 16:4 doi:10.1186/1746-1340-16-4 This article is available from: http://www.chiroandosteo.com/content/16/1/4 © 2008 Bablis et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Trigger points have been shown to be active in many myofascial pain syndromes. Treatment of trigger point pain and dysfunction may be explained through the mechanisms of central and peripheral paradigms. This study aimed to investigate whether the mind/body treatment of Neuro Emotional Technique (NET) could significantly relieve pain sensitivity of trigger points presenting in a cohort of chronic neck pain sufferers. Methods: Sixty participants presenting to a private chiropractic clinic with chronic cervical pain as their primary complaint were sequentially allocated into treatment and control groups. Participants in the treatment group received a short course of Neuro Emotional Technique that consists of muscle testing, general semantics and Traditional Chinese Medicine. The control group received a sham NET protocol. Outcome measurements included pain assessment utilizing a visual analog scale and a pressure gauge algometer. Pain sensitivity was measured at four trigger point locations: suboccipital region (S); levator scapulae region (LS); sternocleidomastoid region (SCM) and temporomandibular region (TMJ). For each outcome measurement and each trigger point, we calculated the change in measurement between pre- and post- treatment. We then examined the relationships between these measurement changes and six independent variables (i.e. treatment group and the above five additional participant variables) using forward stepwise General Linear Model. Results: The visual analog scale (0 to 10) had an improvement of 7.6 at S, 7.2 at LS, 7.5 at SCM and 7.1 at the TMJ in the treatment group compared with no improvement of at S, and an improvement of 0.04 at LS, 0.1 at SCM and 0.1 at the TMJ point in the control group, (P < 0.001). Conclusion: After a short course of NET treatment, measurements of visual analog scale and pressure algometer recordings of four trigger point locations in a cohort of chronic neck pain sufferers were significantly improved when compared to a control group which received a sham protocol of NET. Chronic neck pain sufferers may benefit from NET treatment in the relief of trigger point sensitivity. Further research including long-term randomised controlled trials for the effect of NET on chronic neck pain, and other chronic pain syndromes are recommended. Trial Registration: This trial has been registered and allocated the Australian Clinical Trials Registry (ACTR) number ACTRN012607000358448. The ACTR has met the requirements of the ICMJE's trials registration policy and is an ICMJE acceptable registry. Page 1 of 12 (page number not for citation purposes) Chiropractic & Osteopathy 2008, 16:4 http://www.chiroandosteo.com/content/16/1/4 Background Trigger points have been shown to be active in fibromyal- Trigger points have been defined as discrete, hyperirritable gia [10,11], as well as somatic tenderness secondary to vis- foci usually located within a taut band of skeletal muscle ceral dysfunction [2], migraine and other forms of non- [1]. The point is a well-circumscribed area in which pres- pathological headache [12], shoulder [13] neck [14] and sure produces a characteristic referred pain, tenderness back pain [15]. Specifically, Rosomoff and co-workers and autonomic phenomena [1]. Trigger points are consid- [15] demonstrated that approximately 97% of persons ered an essential defining part of the myofascial pain syn- with chronic intractable pain have trigger points, and of drome, in which widespread or regional muscular pain is these, 45% have a non-dermatomal referred pain. Further- a cause of musculoskeletal dysfunction [2], as well as more, Rosomoff's team demonstrated that 100% of neck being associated with hyperalgesia, restriction of daily pain sufferers possessed the presence of trigger points and function or psychological disturbance [3]. Upon clinical almost 53% of them had non-dermatomal referral [15]. presentation, trigger points are classified depending on However, it is worthy of note that no evidence describes certain characteristics. An active trigger point is defined as the prevalence of trigger points of the neck and face in a one with spontaneous pain, or pain in response to move- normal population. Indirect evidence presented in the ment. It is tender on palpation, and may present with a equine model suggests there to be significant differences referral pattern of pain, not at the site of the trigger point between active trigger points and control points [16]. origin. A latent trigger point is a sensitive spot that causes pain or discomfort only in response to compression. Trig- The diagnosis of a trigger point involves physical exami- ger points are reported to occur more frequently in cases nation by an experienced therapist using a set of cardinal of mechanical neck pain than in matched controls [4]. signs (Table 1) [1]. There have been many studies focused Patients may only become aware of pain when pressure is on the assessment of the reliability of detecting trigger applied to a muscular point of restriction or weakness. points. Lew et al. [17] found that both inter and intra-rater reliability, using two highly trained examiners was poor, The pathogenesis of trigger points is not clear, but it is while Gerwin et al [18] found that extensive training of believed they arise from more than one cause [5]. Fischer four clinicians together resulted in improved reliability for [5] has suggested that trigger points are due to the sensiti- the identification of trigger points. Reeves et al. [19] dem- sation of nerves and the tenderness results from the onstrated a moderate degree of intra and inter examiner decrease in the pain pressure threshold. He further opines reliability in determining the location of trigger points. In that the tissue damage associated with injury causes the older studies values ranged from r = 0.68 to r = 0.86 [19]. release of inflammatory products that increase the sensi- In a study by Delaney and McKee [20], interclass correla- tivity of the nerve to stimulation. These substances tion co-efficient (ICC) revealed inter-rater reliability to be include bradykinins, 5-HT and prostaglandins, though a high (values ranged from ICC = 0.82 to ICC = 0.92), and recent study found tender points in the trapezius muscle intra-rater reliabilities to be high (values ranged from ICC of patients with tension-type headache were not sites of = 0.80 to ICC = 0.91) for the use of a pressure threshold ongoing inflammation [6]. Trigger points are also thought meter in measuring trigger point sensitivity. to arise from acute trauma or repetitive microtrauma, such as lack of exercise, poor nutrition, postural imbalances, In both clinical and experimental practice, a device such vitamin deficiencies, sleep disturbances and joint prob- as the pressure algometer would be of great value for reli- lems [7]. One study suggests overloading of muscle fibres able quantification of trigger point sensitivities, once may lead to involuntary shortening, oxygen and vitamin manually located. Fischer [5] demonstrated that the use of deficiencies and increased metabolic demand on local tis- algometry in the detection of trigger points was a reliable sues [8], and trigger points have been suggested as procedure. He assessed the pressure threshold of deep ten- decreasing the extensibility and contractile efficiency of derness in soft tissues, before and after various forms of muscles, and possibly causing muscle fatigue [9]. This is treatment such as physiotherapy and drug therapy. In yet to be confirmed by research. addition, Reeves et al. [19] reviewed studies that demon- strated the reliability of the pressure algometer. He found Table 1: The Cardinal Signs of a Trigger Point (adapted from Simons, Travell and Simons [1]). Cardinal Signs of a Trigger Point - Presence of a taut band in the target muscle - A nodular point of tenderness - A jump sign: Patient reacts to the application of digital pressure to the taut band or nodular point - Referral of pain on the application of pressure to the taut band or nodule Page 2 of 12 (page number not for citation purposes) Chiropractic & Osteopathy 2008, 16:4 http://www.chiroandosteo.com/content/16/1/4 that an experimenter was able to reliably obtain similar Methods measurements on two occasions, as well as produce simi- This study received ethics approval from the Macquarie lar scores to independent experimenters. He also noted University Ethics Committee, reference